The Basics of the Office Visit
Look at the history form and other relevant materials prior to seeing the patient.
Shake the patient’s hand, sit down, and make eye contact at the start of the visit.
Allow the patient to talk unimpeded for at least 90 seconds.
If the patient has several medical concerns, help him\her decide which ones will be addressed right away and
which will be dealt with during a follow-up visit.
Move the conversation forward with nods, empathetic statements, and open-ended questions.
Use analogies or illustrations to help patients understand medical concepts and treatment options.
Use the patient's words from the opening of the visit to describe your findings at the end.
Put follow-up instructions in writing.
If referring the patient to a specialist or another physician, make the appointment before that patient leaves your office.
Documenting Phone Calls
It is advisable to document phone calls in the chart as soon as possible, especially on very sick patients and ones who ask for advice. You are not required to do this, but good documentation is the best defense against liability; its absence can often ruin the defense. Record the date of the phone call, the nature of the complaint and the advice you gave. If the outcome of a case depends on a credibility battle between you and the patient, this documentation may provide the crucial evidence you need.
The Physician as an Expert Witness
You will examine and treat patients whose medical conditions arise from child abuse, trauma, workers’ compensation or comparable situations that may involve legal action in which you are not a party. In these situations, you may be required to testify about the patient’s medical evaluation and treatment as the treating physician. If you are not the treating physician you should avoid becoming involved in legal proceedings where possible.
In discussing potential testimony as a treating physician with an attorney, it is essential you
make it clear that your role is as a treating physician and not as an expert witness. Otherwise,
the attorney may expect you to make greater time commitments and provide live testimony at
trial when this was not your intention. You cannot be compelled to become a non-treating
expert witness against your will.
You may be asked to be an expert in cases in which you have not served as the treating
physician. The issue is usually whether another physician met or failed to meet the standard
of care, or was the cause of a patient’s injury or illness.
For additional Risk Management tips, contact Deborah Kozora, Director of Risk Management
at 502-895-6404.
Look at the history form and other relevant materials prior to seeing the patient.
Shake the patient’s hand, sit down, and make eye contact at the start of the visit.
Allow the patient to talk unimpeded for at least 90 seconds.
If the patient has several medical concerns, help him\her decide which ones will be addressed right away and
which will be dealt with during a follow-up visit.
Move the conversation forward with nods, empathetic statements, and open-ended questions.
Use analogies or illustrations to help patients understand medical concepts and treatment options.
Use the patient's words from the opening of the visit to describe your findings at the end.
Put follow-up instructions in writing.
If referring the patient to a specialist or another physician, make the appointment before that patient leaves your office.
Documenting Phone Calls
It is advisable to document phone calls in the chart as soon as possible, especially on very sick patients and ones who ask for advice. You are not required to do this, but good documentation is the best defense against liability; its absence can often ruin the defense. Record the date of the phone call, the nature of the complaint and the advice you gave. If the outcome of a case depends on a credibility battle between you and the patient, this documentation may provide the crucial evidence you need.
The Physician as an Expert Witness
You will examine and treat patients whose medical conditions arise from child abuse, trauma, workers’ compensation or comparable situations that may involve legal action in which you are not a party. In these situations, you may be required to testify about the patient’s medical evaluation and treatment as the treating physician. If you are not the treating physician you should avoid becoming involved in legal proceedings where possible.
In discussing potential testimony as a treating physician with an attorney, it is essential you
make it clear that your role is as a treating physician and not as an expert witness. Otherwise,
the attorney may expect you to make greater time commitments and provide live testimony at
trial when this was not your intention. You cannot be compelled to become a non-treating
expert witness against your will.
You may be asked to be an expert in cases in which you have not served as the treating
physician. The issue is usually whether another physician met or failed to meet the standard
of care, or was the cause of a patient’s injury or illness.
For additional Risk Management tips, contact Deborah Kozora, Director of Risk Management
at 502-895-6404.
